Palliative Care and Residential care settings · workforce in 2008 Source: (Grant Thornton, 2010, pp. 109, citing In Touch issue 112, April 2010, New Zealand Aged Care Association)

Palliative Care and Residential care settings

Hospice New Zealand

Palliative Care Lecture Series

7 August 2014

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Kate Gibb

Nursing Director, Older People – Population Health

Canterbury District Health Board

Overview

My background

Some context

What is aged residential care (ARC) in NZ?

What is the extent of palliative care provision in ARC

Perceptions of ARC

Challenges – a case study

Innovations

Opportunities for the future

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Our population is ageing

The population aged 65 years and over has increased from 11 per cent of the total population in 1991 to 13 per cent in 2009.

By the late 2020s, the number of older New Zealanders is forecast to outnumber the youth and child populations, with one million New Zealanders predicted to be aged over 65.

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Direction of travel…

Source: Ministry of Health (2012) Briefing to the Incoming Minister

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Palliative Care Council

Phase 1 (2011) – 511,200 people over 65years in NZ; 1 in 20

living in residential care

Over 40% of those over 85yrs who die of a condition amendable to palliative care, did so in residential care

Phase 2 (2013) – Limited data on the extent of palliative care

provision in ARC

Increasing dependency overall

Increased utilisation as a setting for end of life care on discharge from acute hospitals

Work in progress – PCC Project: Palliative Care in Aged

Residential Care

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Deaths in New Zealand 2000-2010

30.1% of all deaths are over age 85; 60.1% are over age 75 and 77.4% are

over age 65.

Source: Analysis of Ministry of Health MORT data 2000 to 2010 7

Historic Deaths and Future Projections by Age Band

Deaths will change in their distribution across age groups. Expected to be

a continued decline in deaths under age 65 and age 65-74, with a dramatic

increase in the number of deaths over age 85.

Source: Palliative Care Council, Working Paper No. 1, July 2013. Drawn using data from Statistics New Zealand; personal communication Joanna Broad. 8

Trajectories at the End of Life

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Source: Lynn, J., & Adamson, D. M. (2003). Living Well at the End of Life. Adapting Health Care to Serious Chronic Illness in Old Age. 2003. RAND Health.

Implications of older deaths

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The major challenge for palliative care will be that not only will

the number of deaths be increasing, but they will be increasing

in older age bands.

These deaths are likely to be occurring to people with more co-

morbidities and a high prevalence of dementia.

If current patterns of end-of-life care continue most of these

deaths over age 85 will occur in residential aged care facilities

after an extended period of care.

What is aged residential care in NZ?

Four service types:

Rest home, intended for residents with the lowest level of dependency in residential care

Private geriatric hospital, intended for residents who require 24-hour nursing supervision

Specialist dementia services, intended to minimise risks associated with the confused states of residents with dementia

Psychogeriatric, intended for residents with an organic illness at the extreme end of dementia and defined by clinicians as those with features of behavioural and psychological symptoms of dementia (BPSD).

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Facilities and bed types

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Source: Grant Thorndon (2010) Aged Residential Care Service

Review. September 2010. Wellington: District Health Board

Shared Services, New Zealand Aged Care Association.

Aged Residential Care Facilities and Bed Types in New

Zealand in 2009

36,100 beds in the sector as at January 2014(Ministry of Health, 2014)

68% for profit; 32% not-for-profit

37% of residential care facilities co-located with retirement

villages(Grant Thorndon ARC Service Review, 2010)

Roughly 30,000 NZers in residential care at any one time(NZ Treasury, 2013)

Age of entry to residential care is progressively increasing:

median age at admission 79yrs in 1988; 83yrs in 2008(Broad et.al. 2011; analysis of data from the OPAL study 1988-2008)

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The changing face of aged residential care

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The changing face of ARC

Between 1998 and 2008, the proportion of the population of NZers

over 65yrs

in rest home care ↓

in hospital care ↑

over 85yrs

in rest home care ↓

in hospital care ↑ (113% increase in this population)

More women in care than men but the gap is closing

Age at admission ↑

Length of stay ↓

(Boyd, 2009)

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The changing face of ARC

Increasing dependency:

Bedbound patients - ↑to 21% from 14%

Memory loss, disorientation to time, persistent wandering,

complete disorientation – all ↑ Continence –

Independent toileting ↓

Dependent toileting ↑

Urinary and faecal incontinence ↑

Night care – needing help at least once / night ↑

Impaired communication ↑(Boyd, 2009)

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Palliative care and aged residential care

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Place of Death 2000-2010

34.2% in hospital, 30.7% in residential care and 22.3% in private residence.

Note that this seriously undercounts hospice involvement as only hospice

inpatient unit available as a place of death.


Place of Death 2010 after Hospice Adjustment

The patterns (not actual data) from the hospice benchmarking data in 2012

have been applied by indexing the deaths of clients in other settings to deaths

in hospice inpatient units. The patterns were then applied to this MORT data.

Source: Analysis of Ministry of Health MORT data 2000 to 2010; with

data from Hospice NZ19


Over the period, deaths in public hospital and residential care have narrowed

with the growth in deaths in residential care. Some increase in deaths in

hospice inpatient unit.

Analysis of Ministry of Health MORT data 2000 to 201020

Place of Death 2000-2010 Male

Hospital and private residence are most common places for male deaths.


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Place of Death 2000-2010 Female

Residential care is most common place for female deaths, with private

residence much smaller than residential care or hospital.


Place of Death 2000-2010 Age 85+

For deaths over age 85, 54.8% in residential care and only 9.9% in private

residence. Some deaths in public hospital likely to be after transfer from

residential care.



18.6% of deaths from Neoplasms in hospice inpatient unit. 68.4% of deaths

from mental, behavioural and nervous system conditions are in residential care.


ARC staff profile

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Aged care staff profile in 2008

Source: Grant Thorndon Review, 2010

Hospice capability

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Source: Palliative Care Council National Health

Needs Assessment for Palliative Care, Phase 2

Report (2013)

An ageing workforce

Age profile of aged residential care

workforce in 2008

Source: (Grant Thornton, 2010, pp. 109, citing In Touch issue

112, April 2010, New Zealand Aged Care Association)27

General practice and ARC

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After-hours Medical Care Arrangements in Residential Aged

Care, OPAL Study 2008

Data source: Boyd et; al. (2009) Changes in Aged Care Residents' Characteristics

and Dependency in Auckland 1988 to 2008. Findings from OPAL 10/9/8 Older

Persons' Ability Level Census. 2009. Auckland: University of Auckland.

Perceptions of ARC

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“Our dirty little secret – abuse of the elderly””

“Carnage at the rest home door”

“Rest home residents fight eviction”

“Flesh disease at rest homes”

“Rest home complaints soar”

“Immigrants “degraded” by work in rest homes”

“Deadly secrets could be exposed”

“Resthome lockdown ends”

“Lifting the lid on aged care in New Zealand … some facilities likened to chicken farms”

“I think it’s a system of wrenching people out of their natural environment and sticking them into an institution and charging them their life savings to stay there and kidding them that they are happy when they are not. I look upon them as battery hens”

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Perceptions of ARC

Colmar Brunton telephone survey conducted in May 2010 (1009 participants):

Over 1/3 had experience of the sector

Those “with experience” were much more favourable than those without experience

Nearly six in ten of those with experience think the sector is better than how it is presented in the news media

Those with friends or family who have been in care for a longer period are more likely to think the sector is better than what is presented in the news media

71% of those “with experience” reported their overall impression of aged care facilities as “good” or “very good”, compared with 55% with no direct experience

Those with no direct experience base their opinion on other personal experience, stories in the media, and what close friends or family have said

17% of those with no direct experience thought rest homes and aged residential care facilities had worsened over the previous three years

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Caring counts

“The respect and value shown to older people in New Zealand is linked to the respect and value shown to their carers.

While society continues to devalue older people, the aged care sector will remain marginalised in terms of both status and in adequacy of resourcing.”

‘Caring Counts’

Human Rights Commission Enquiry into Aged Care, 2012

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Case study – “inappropriate hospitalisation”

Resident with advanced dementia, appears “unwell”. No close relatives living nearby; designated “family contact” some distance away and rarely in contact

No obvious sign of infection, constipation, or serious illness, but staff ‘instinctively’ knew something was wrong

Suspected a bronchopneumonia and that she was now in a terminal phase

GP visit requested; no obvious physiological changes so felt no significant issues to address

Resident continued to deteriorate; no definite diagnosis or plan in place so a further GP visit requested via After Hours service

After Hours GP ordered transfer to hospital despite nursing staff feeling this wasn’t the appropriate course of action. Relative contacted and updated, did not attend.

Ambulance took some time to arrive

Carer accompanied resident to A&E; resident significantly deteriorated by this time.

Tests and investigations commenced in ED however the resident passed away soon after arrival, on an emergency department trolley, with the carer present

An A&E consultant emailed the facility manager the following week expressing concern about their practice in “sending residents to hospital to die”

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“Inappropriate hospitalisation”

Underlying issues:

Access to diagnostics

Poor communication between primary and secondary care

Excessive cautiousness of clinicians to manage patients in the community

Clinicians unfamiliar with the resident – eg mistaking problems as acute rather than chronic

Also –

Lack of recognition of the importance of nursing staff assessments of subtle behavioural change, in the absence of specific physiological change (eg elevated temp)

And –

society’s understanding of death and dying, in the context of medicalization, and beliefs around the role of the acute hospital

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Ensuring residents’ wishes are respected in the event of a deterioration requires …

Knowing what a resident wants in terms of future care and ensuring these wishes are clearly documented in a format which will be recognisable and credible to clinicians involved in the resident’s care

Recognition and anticipation of potential problems and early intervention to prevent crisis events

Confidence of nursing staff when talking to other people involved in the resident’s care whether family members, other staff, doctors or out of hours providers and a willingness to act as an advocate for the resident where required

Confident staff are able to challenge plans that they feel are not in the resident’s best interest

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To recap …

An ageing population, and an increasing demand projected for ARC over time

Increasing dependency of ARC population, and decreased length of stay – residents are admitted older, frailer, and with more complex needs

The most common place of death for women, over 85s, and for people with dementia

Increasingly, less time to establish relationships with residents and families who have been under significant stress during acute illness and after prolonged period of care in the community

Pre-existing perceptions and beliefs about the likely standard of care on admission to ARC, and long held beliefs around the role of the acute hospital, and ‘rescue medicine’

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Innovations and opportunities

Integrated approach to palliative care in ARC

Advance Care Planning

Tailored education, training and support – Hospice NZ

Fundamentals of palliative care

InterRAI Palliative Care Assessment

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Develop linkages and integration across ARC, Older Persons Health, and palliative care specialist services

A palliative approach to aged care

Consideration of quality standards and guidelines for palliative care in ARC

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A framework for integrated care

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Source: Ministry of Health (2012) Resource and Capability Framework for

Integrated Adult Palliative Care Services in New Zealand. December 2012.

Wellington: Ministry of Health Manatū Hauora

Strengthening the older persons nursing workforce

Strategies to strengthen ARC nursing:

Creating a learning environment

Availability of support and expertise

Effective succession planning

Strengthening linkages and integrated care

Positively promoting and valuing the breadth of the ARC nurse

role and the education and career opportunities in ARC.

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Kate GibbNursing Director, Older People – Population Health

Canterbury District Health Board

Email: [email protected] 03 3377899 xtn 68001Mobile: 021 766025

With thanks and acknowledgement:Prof. Heather McLeod

Senior Analyst, Palliative CareCancer Control New Zealand

Email: [email protected]

www.cancercontrolnz.govt.nz/palliative-care

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mailto:[email protected]

http://www.cancercontrolnz.govt.nz/palliative-care

Documents

Palliative Care and Residential care settings · workforce in 2008 Source: (Grant Thornton, 2010, pp. 109, citing In Touch issue 112, April 2010, New Zealand Aged Care Association)